99 7 Wanted Babies, Excess Fetuses The Middle East’s In Vitro Fertilization, High-Order Multiple Pregnancy, Fetal Reduction Nexus Marcia C. Inhorn Although rarely acknowledged by global health agencies, infertility is an important reproductive health problem, affecting between 50 million and 185 million people worldwide (Boivin et al. 2007; Mascarenhas et al. 2012; Rutstein and Shah 2004). Approximately 8 percent to 12 percent of reproductive -aged couples suffer from infertility in any given population, but in some regions of the world, particularly sub-Saharan Africa, South Asia, and the Middle East and North Africa (MENA), infertility rates are significantly higher, ranging from 10 percent to 30 percent (Mascarenhas et al. 2012; Nachtigall 2006; Ombelet, Cooke, et al. 2008; Ombelet, Devroey, et al. 2008). In the MENA region, an estimated 10 percent to 22 percent of all reproductive-aged couples suffer from infertility (Serour 2008b; Soraya Tremayne, personal communication 2014), with the condition taking three main forms: tubal infertility due to sterilizing reproductive tract infections; polycystic ovary syndrome, a form of ovulatory infertility related to the region ’s twin epidemics of obesity and diabetes; and male infertility, mostly genetic in nature, which contributes to at least 60 percent of all Middle Eastern infertility cases (Inhorn 2003b, 2012, 2015). Given the region’s significant infertility problems, assisted reproductive technologies, including in vitro fertilization (IVF), have spread rapidly across the region. Only two years after the 1978 birth of Louise Brown, the world’s first IVF baby, a fatwa from Egypt’s renowned Islamic university, Al Azhar, condoned the use of IVF to overcome marital infertility. By 1986, IVF centers had opened in Egypt, Jordan, and Saudi Arabia. By 1996, Egypt alone hosted more than 50 IVF clinics (Inhorn 2003b). Today, the MENA region boasts one of the largest, most robust IVF industries in the world. As shown in Table 7.1, the MENA region ranks second only to Asia (with its IVFpopulous nations of China, India, and Japan) in total number of IVF clinics 100 Abortion Pills, Test Tube Babies, and Sex Toys (Jones et al. 2010). Furthermore, virtually every MENA nation, including those not represented in Table 7.1, hosts at least one IVF clinic—even impoverished nations such as Yemen and Palestine, ad war-torn countries such as Iraq and Syria. Yet, the presence of a strong regional IVF industry has led to new issues and concerns. One of the major emergent problems is the dramatic increase in the rate of multifetal pregnancies. Although multifetal pregnancies are often thrilling to Middle Eastern IVF patients who have waited for years to have a baby and desperately desire multiples in order to complete their families in a single IVF attempt, such pregnancies are the source of significant risks to both the prospective mother and her children. Maternal risks include gestational diabetes, hypertension and preeclampsia, pregnancy loss, and postpartum hemorrhage. Infants born as part of a multiple pregnancy are at a greater risk of prematurity, low birth weight, chronic lung disease, cerebral palsy, a range of cognitive delays, and higher rates of perinatal death (American College of Obstetricians and Gynecologists 2013). Furthermore, the medical costs associated with multiple births escalate with each additional fetus (Collins 2002). Health care expenditures “are quadrupled for twins and are 10 times higher for triplets” (American College of Obstetricians and Gynecologists 2013, 2). Given the risks of multifetal pregnancies and their increasing incidence in the MENA region, a new problem has emerged—one that will be described in this chapter as the IVF-HOMP-MFPR nexus. This term captures the intersection of three medical realities: the transfer of too many IVF embryos into infertile women’s wombs in IVF clinics across the region; the resulting high-order multiple pregnancies (HOMPs), with triplets, quadruplets, and beyond; and the introduction of a medical procedure to reduce these high-risk HOMP pregnancies, which is called multifetal pregnancy reduction (MFPR). In short, across the MENA region, IVF cycles are producing “wanted babies” for infertile couples, but also many “excess fetuses,” which are being selectively aborted through MFPR. This unlikely juxtaposition of two opposing reproductive technologies—IVF and abortion—produces myriad problems for IVF patients, especially those living in MENA countries where access to abortion is severely restricted. This chapter on the IVF-HOMP-MFPR nexus is based on anthropological field research I carried out in six IVF clinics in three MENA countries: Egypt (1988–1989, 1996), Lebanon (2003), and the United Arab Emirates (UAE; 2007). In particular, I undertook ethnographic interviews...

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